Exam 3 - Neurologic Disorders

Question 1

Types of concussion & be able to recognize the type given its description

Answer 1

Mild Concussion (Grades I-III)
- Temporary axonal disturbances causing attention and memory deficits but no loss of consciousness
- Grade I – confusion, disorientation, and momentary amnesia
- Grade II – momentary confusion and retrograde amnesia
- Grade III – confusion with retrograde and anterograde amnesia
Classic Cerebral Concussion
- Grade IV:
o Disconnection of cerebral systems from the brainstem and reticular activating system
o Physiologic and neurologic dysfunction without substantial anatomic disruption
o Loss of consciousness (<6 hours)
o Anterograde and retrograde amnesia
o Uncomplicated (no focal injury) or complicated (focal)

Question 2

Pathophysiology & causes/triggers including level of spinal cord injury of autonomic dysreflexia

Answer 2

• Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system
• Stimulation of the sensory receptors below the level of the cord lesion - injury T-6 or higher
• Causes:
  o Restrictive clothing
  o Pressure ulcer
  o Full bladder or UTI
  o Fecal impaction

Question 3

Physical assessment & clinical findings for arteriovenous malformation (AVM)

Answer 3

• (What it is: Vein and artery connect in unnatural place, lack capillary)
• Causes bruit (auscultating)
• Typically present before 40 years of age and affect men and women equally
• Slowly progressive neurologic deficits
• Intracerebral and subarachnoid hemorrhage
• Seizures
• Headache – often severe, c/o throbbing and synchronous w/heartbeat
• Other focal symptoms depend on location of lesion and visual symptoms (i.e., diplopia and hemianopia), hemiparesis, mental deterioration, and speech deficits
• Definitive diagnosis often is obtained through cerebral angiography

Question 4

Disorders that cause a positive Kernig & Brudzinski sign

Answer 4

• Encephalitis or meningitis – presence of nuchal rigidity and a positive Kernig’s sign or Brudzinski’s sign
• Subarachnoid hemorrhage – blood escapes from defective or injured vasculature into the subarachnoid space

Question 5

Most common primary central nervous system tumor

Answer 5

• Astrocytoma – largely tumors of adults but still the leading primary brain tumor in children

Question 6

Pathophysiology of multiple sclerosis

Answer 6

• MS is chronic, progressive, noncontagious degenerative disease of the CNS characterized by inflammation and selective destruction of CNS myelin
• Damage occurs in diffuse patches throughout the nervous system and slows or stops nerve impulses

Question 7

Coup injury

Answer 7

• Injury directly below the point of impact
• Most contusions result from a blunt blow to the head that causes the brain to make sudden impact with the skull
• The initial area the brain impacts with the skull is referred to as the coup

Question 8

Contrecoup/countercoup injury

Answer 8

• Injury on the pole opposite the site of impact
• After the brain has initial impact with the skull, the brain then rebounds and impacts with the opposite side of the skull, causing another area of damage referred to as the countercoup

Question 9

Pathophysiology of myasthenia gravis

Answer 9

• Chronic autoimmune disease
• IgG antibody produced against acetylcholine receptors – leads to disruption at neuromuscular junction
• Disruption causes weakness of the voluntary skeletal muscles because nerves aren’t stimulated as much
• Muscle weakness typically increases during periods of activity and improves after periods of rest
• Muscles that control breathing and neck and limb movements may be affected
• Exact trigger for autoimmune response is unclear but the thymus gland is thought to play a role

Question 10

Client teaching about the prevention of myasthenic and cholinergic crises in myasthenia gravis

Answer 10

• The priority for both is to maintain adequate respiratory function
• M: caused by undermedication; C: caused by overmedication
• M: hold meds (increase secretions), remove secretions
• C: drugs withheld while on vent, Atropine given and repeated if necessary, causes muscle twitching, observe for thickened secretions, can’t cough
• Tensilon is test administered - muscles get stronger with M crisis

Question 11

Pathophysiology of & risk factors for Guillain-Barré syndrome

Answer 11

• Acquired inflammatory disease causing demyelination of the peripheral nerves with relative sparing of axons
• Preceded by a bacterial or viral illness
• Immune system overreacts to the infection and destroys the myelin sheath
• Acute onset, ascending bilaterally (toes to head) weakness leading to motor paralysis, infectious neuronitis
• Humoral and cellular immunologic reaction
• Risk factors:
  o Possibly autoimmune
  o Association with immunizations
  o Frequently preceded by mild respiratory or intestinal infection

Question 12

“FASTG”

Answer 12

Stroke assessment
- F facial droop (cranial nerves) – show teeth or smile
Abnormal – one side of face does not move as well as the other side
- A arm drift (motor) – hold arms out, palms down and close eyes
Abnormal – one arm cannot be lifted or drifts down
- S speech – repeat phrase
Abnormal – wrong or inappropriate words or unable to speak (aphasia) caused by left hemispheric deficit; slurred words (dysarthria) caused by cranial nerve deficit
- T time last seen or known normal
Time is major determinant in what interventions may be effective
- G glucose
Blood glucose used to rule out hypoglycemia as a reversible cause of stroke-like symptoms
High priority assessment tool, especially in diabetic patients or those with other potential reasons to be hypoglycemic

Question 13

Cavernous angioma

description

Answer 13

• Blood vessel malformation
• Large blood filled spaces (does not contain tissues of organ it inhabits)
• Slow blood flow
• Symptoms: seizures, headaches, hemorrhage or compression of surrounding brain tissue, weakness, numbness, double vision, visual disturbance, language difficulties

Question 14

Capillary telangiectasia

description

Answer 14

• Small collection of abnormally dilated capillaries deep within otherwise normal brain tissue

Question 15

Arteriovenous angioma

description

Answer 15

• Congenital tumor
• Consists of a tangle of coiled, usually dilated arteries and veins, islets of sclerosed brain tissue, and occasionally, cartilaginous cells
• Lesion may be distinguished by an intracranial bruit, found in pia mater
• May grow to project deeply into the brain, causing seizures and progressive hemiparesis

Question 16

Arteriovenous malformation

description

Answer 16

• Defect of the circulatory system

- Abnormal connection of artery and vein surpassing any capillaries

Question 17

Pathophysiology of different types of strokes

Answer 17

• Clot/ischemic strokes (80%) – caused by either a thrombus (a stationary clot that forms in a blood vessel) or an embolus (a clot that travels through the bloodstream and becomes lodged in a vessel)
  Decreased blood supply to focal area of brain
  Lacunar: complete blockage of artery
  Embolic: in the brain
  Thrombotic: in artery leading to brain
• Hemorrhagic (20%): blood vessel rupture (not due to trauma)
  Subarachnoid hemorrhage: bleeding around the brain
  Can be caused by broken open aneurysm

Question 18

Clinical manifestations found immediately after spinal cord injury

Answer 18

• Necrosis consumes 40% within 4 hours and 70% within 24 hours
• Cord swelling increases degree of dysfunction – release of toxic excitatory amino acids, accumulation of endogenous opiates, lipid hydrolysis with production of active metabolites, and local free radical release
• Produce further ischemia, vascular damage, and necrosis of tissue
• Neurogenic shock: loss of sympathetic outflow
  o Vasodilation, hypotension, bradycardia, hypothermia
• Compression fracture, …plegic

Question 19

right cerebral vascular accident/stroke

Clinical manifestations

Answer 19

• Left body paralysis
• Short attention span
• Spacial/perceptual difficulties
• Minimizes problems
• Visual field difficulties
• Impaired judgment
• Impulsive
• Impaired time concept

Question 20

left cerebral vascular accident/stroke

Clinical manifestations

Answer 20

• Right body paralysis
• Impaired speech and language
• Visual field deficits
• Depression and anxiety
• Impaired language and math skills
• Slow performance
• Aware of deficits

Question 21

The client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

1. Strict adherence to a bowel retraining program
2. Keeping the linen wrinkle-free under the client
3. Preventing unnecessary pressure on the lower limbs
4. Limiting bladder catheterization to once every 12 hours

Answer 21

4

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

Question 22

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

1. Hyperreflexia
2. Positive reflexes
3. Reflex emptying of the bladder
4. Flaccid paralysis

Answer 22

4

Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

Question 23

The nurse is teaching the client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

1. Eating large, well-balanced meals
2. Doing muscle-strengthening exercises
3. Doing all chores early in the day while less fatigued
4. Taking medications on time to maintain therapeutic blood levels

Answer 23

4

Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

Question 24

The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of:

1. Seizures or trauma to the brain
2. Meningitis during the last 5 years
3. Back injury or trauma to the spinal cord
4. Respiratory or gastrointestinal infection during the previous month

Answer 24

4

Guillain-Barre syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.

Question 25

The client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?

1. Giving client full control over care decisions and restricting visitors
2. Providing positive feedback and encouraging active range of motion
3. Providing information, giving positive feedback, and encouraging relaxation
4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

Answer 25

3

The client with Guillain-Barre syndrome experiences fear and anxiety from ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

Question 26

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following essential items into the client’s room?

1. Nebulizer and pulse oximeter
2. Blood pressure cuff and flashlight
3. Flashlight and incentive spirometer
4. Electrocardiographic monitoring electrodes and intubation tray

Answer 26

4

The client with Guillain-Barre syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of the electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely.

Question 27

The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:

1. A negative Kernig sign
2. Absence of nuchal rigidity
3. A positive Brudzinski sign
4. A Glasgow Coma Scale score of 15

Answer 27

3

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and positive Kernig sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glasgow Coma Scale score of 15 is a perfect score and indicates that the client is awake and alert, with no neurological deficits.

Question 28

The nurse is caring for a client who has had a right-sided stroke. What would be appropriate nursing care for this client?

1. Performing passive ROM exercises to affected side, active ROM on unaffected side
2. Placing food on the affected side of the client’s mouth
3. Applying hot packs to the right to decrease muscle spasms
4. Turning client every 2 hours and maintaining position on the right side for 2 hours

Answer 28

1

The rehabilitation program for a client who has had a stroke includes actions that prevent deformity (passive range of motion on affected side and active ROM on the unaffected side) and prevent complications that may be associated with immobility. The client’s affected side should be protected, and food should be placed on the unaffected side so that the client can control it. The client should be turned to his right (affected side) but for shorter periods of time. Hot packs would not be applied to decrease spasticity or spasms.

Question 29

The nurse is assessing a client with a tentative diagnosis of multiple sclerosis. Which assessment finding would the nurse identify as a characteristic of early signs of multiple sclerosis (MS)?

1. Diplopia
2. Resting tremor
3. Flaccid paralysis
4. Unilateral neglect

Answer 29

1

Early signs of multiple sclerosis (MS) include difficulty with fine motor movement, especially of the head and neck. Often, visual disturbance is the most ominous sign. Tremors, flaccid paralysis, and unilateral neglect are not seen in the client with MS.

Question 30

A client in the acute phase of Guillain-Barre syndrome is admitted with weakness and numbness of the lower extremities, along with continual pain that worsens at night. What would be a priority nursing diagnosis?

1. Fear related to uncertain outcome and seriousness of the problem
2. Acute pain related to paresthesias, muscle aches, and cramps
3. Impaired spontaneous ventilation related to progression of the disease
4. Risk for aspiration related to dysphagia

Answer 30

3

Guillain-Barre is an acute and rapidly progressing condition affecting the peripheral nervous system characterized by an ascending level of paralysis leading to a serious complication of respiratory failure. This necessitates constant monitoring of the respiratory system. Although other autonomic dysfunctions can occur (requiring the other assessments), such as orthostatic hypotension, hypertension, heart block, bowel and bladder dysfunction, facial flushing, diaphoresis, and lower brainstem involvement (cranial nerves), respiratory problems are the priority.